Nokea
In the middle of bathing a client, the unit secretary notifies the nurse that there is an emergency telephone call. Which action should the nurse implement to best assure client safety?
- A. Quickly finish the bath before answering the call.
- B. Immediately leave the client's room and answer the call.
- C. Cover the client, place the call light within reach, and then leave to answer the call.
- D. Leave the door open and ask staff to monitor the client, and then leave to answer the call.
Correct Answer: C
Rationale: Because the telephone call is an emergency, the nurse may need to answer it. To maintain privacy and safety, the nurse covers the client and places the call light within the client's reach. Additionally, the client's door should be closed or the room curtains pulled around the bathing area. The other appropriate action is to ask another nurse to accept the call. This, however, is not one of the options. None of the other options effectively meet the client's safety needs.
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The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next?
- A. Inflate the balloon with water.
- B. Secure the catheter to the client.
- C. Measure the initial urine output.
- D. Advance the catheter 2.5 to 5cm .
Correct Answer: D
Rationale: The balloon of a urinary catheter is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5cm further after urine begins to flow so as to provide sufficient space to inflate the balloon. The balloon is not inflated as soon as urine appears because the balloon could be located in the urethra. After the insertion procedure and inflation of the balloon, the nurse secures the catheter to the client's leg and then measures the initial urine output.
The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions should the nurse implement for this client?
- A. Enteric precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: C
Rationale: Contact precautions include standard precautions and require the use of barrier precautions such as gloves and goggles. Contact precautions are used for clients who have diarrhea, draining wounds, or methicillin-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through inanimate objects or surfaces that the pathogen has contaminated, such as instruments, linens, dressing materials, or hands. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Droplet and airborne precautions are used if the organism is transmitted via the respiratory tract.
A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which priority safety actions should the nurse implement in the postprocedure period? Select all that apply.
- A. Restricting visitors
- B. Checking the client's groin for bleeding
- C. Encouraging the client to increase fluid intake
- D. Placing the client's bed in the high-Fowler's position
- E. Instructing the client to move the toes when checking circulation, motion, and sensation
Correct Answer: B,C,E
Rationale: Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the primary health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high-Fowler's position (flexion) increases the risk of occlusion or hemorrhage.
The nurse notes that a client's lithium level is 3.9 \mathrm{mEq} / \mathrm{L}(3.9 \mathrm{mmol} / \mathrm{L}) . Based on this data, which priority intervention should the nurse implement?
- A. Determining visual acuity
- B. Assisting with ambulation
- C. Monitoring intake and output
- D. Instituting seizure precautions
Correct Answer: D
Rationale: The lithium level must be monitored closely in a client taking lithium. A therapeutic regimen is designed to attain a serum lithium level of 0.8 to 1.2 \mathrm{mEq} / \mathrm{L}(0.8 to 1.2 \mathrm{mmol} / \mathrm{L}) for maintenance treatment. A level of 3.9 \mathrm{mEq} / \mathrm{L (3.9 \mathrm{mmol} / \mathrm{L}) is in the toxic range, and seizures may occur at levels of 3.5 \mathrm{mEq} / \mathrm{L (3.5 \mathrm{mmol} / \mathrm{L}) and higher. While the remaining options are appropriate interventions, they are not the priority because they are not related to the possibility of toxicity.
A registered nurse is delegating activities to the nursing staff. Which activities can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply.
- A. Collecting a urine specimen from a client
- B. Obtaining frequent oral temperatures on a client
- C. Assessing a client who returned from the recovery room 6 hours ago
- D. Assisting a post-cardiac catheterization client who needs to lie flat to eat lunch
- E. Accompanying a client being discharged to meet his spouse at the hospital exit door
Correct Answer: A,B,D,E
Rationale: Unlicensed assistive personnel (UAP) are trained to perform noninvasive tasks and those that meet basic client needs, such as collecting specimens, taking vital signs, assisting with activities of daily living, and escorting clients. Therefore, collecting a urine specimen, obtaining frequent oral temperatures, assisting a post-cardiac catheterization client to eat lunch while lying flat, and accompanying a client to the hospital exit are appropriate tasks for the UAP. Assessing a client who returned from the recovery room requires clinical judgment and is a task for a licensed nurse, as it involves evaluating the client's condition and identifying potential complications.